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Total Laparoscopic Hysterectomy

What is a Total Laparoscopic Hysterectomy?

A Total Laparoscopic Hysterectomy (TLH) is an operation to remove the uterus with the aid of an operating telescope called a laparoscope. This tiny instrument is inserted through a small cut in the abdominal wall and allows the surgeon to see into your abdomen. The major benefit of this kind of hysterectomy is that you will not need to have a large cut in your abdomen and your recovery is usually much faster.

Your cervix, or the neck of the womb, is also removed during this operation. Your ovaries may or may not be removed depending on your wishes and your condition.

Not every patient is suited to this operation. If it is suitable for you, your gynaecologist will advise you.

What happens during the surgery?

You will be under a general anaesthetic.

Carbon dioxide gas will be used to inflate the abdomen and to create space for the surgeon to work. The surgeon will insert the laparoscope through the umbilicus (belly button) so that the team can see what they are doing.

The surgeon will also make three small cuts in the abdomen to insert other instruments that are needed for the surgery.

The surgeon will have a very clear view of the inside of your abdomen and can use the image on the screen to free your uterus from the tubes, ligaments and blood vessels on each side. A cut will also be made around the cervix and into the vagina to enable the uterus to be removed through the vagina. The cut will be closed with absorbable stitches.

If the ovaries and tubes are to be removed at the same time they will also be freed and removed through the vagina.

The pelvic cavity will be washed out with a sterile solution. The gas will be removed (as much as possible) and the wounds closed with sutures.

Sometimes, a small drain tube is inserted through one of the wounds to drain some blood stained fluid and gas after the operation. This is removed the following day.

After the operation

You will wake up with a tube in your bladder (catheter), an IV drip to replace lost fluids, a drain tube, as described above, and an oxygen mask.

After four hours you will be offered something to drink.

You will probably be able to eat breakfast the following day. You will also be able to shower and have the drip and catheter removed. Most patients are discharged on the second day.

Complications

All operations have a small risk of complications. For some people the risks are higher. For example, your risk of experiencing complications will increase if you smoke, have heart disease, diabetes or you are overweight.

Before the operation write down any questions or concerns that you may have. Include anything that you think may increase your risk of complications. This will be helpful when you are talking with the surgical team, who can advise and reassure you. Overall, if you are offered an operation it is because we believe the benefits far outweigh the potential for harm.

General risks with abdominal surgery?

Wound infection - all women receive antibiotics in the drip to lessen the chance of this.

Bleeding - a small percentage of women may require a blood transfusion during or after the procedure. Rarely, women will have bleeding after the operation and will need to have another operation.

Blood clots in legs (deep venous thrombosis) - this is rare but sometimes blood clots will break off and travel to the lungs (pulmonary embolism). Most patients are offered medication to reduce the risk.

As tissues heal inside the abdomen, loops of bowel or other tissues may become stuck together (adhesions), which occasionally causes pain and may require further surgery.

Severe complication such as a heart attack due to strain on the heart during the anaesthetic, or even death.

Specific risks with laparoscopic hysterectomy

Urine infection which may require antibiotics.

Damage to the bladder or ureters.

Bowel damage (1 in 1000) or major blood vessel damage (1 in 3000 for all laparoscopies) which may require a large cut on the abdomen (laparotomy) in order to correct. It is unusual, but occasionally this condition will not be recognised for some time.

If during the operation the surgeon decides that it is not safe to continue using the laparoscope it may be decided to convert to a conventional abdominal hysterectomy.

If you have your ovaries removed and you were not already menopausal, you may begin to experience hot flushes.

A hysterectomy is irreversible so there is no possibility of pregnancy after this operation.

Recovery

Pain/bloating

Some pain is usual. You may also experience a period-like, cramping sensation or pain in the shoulders. This is thought to be due the Carbon Dioxide gas used to inflate the abdomen. This, and a sensation of bloating, usually lasts one to two days but in some cases it will last weeks. Try simple analgesics such as paracetamol (Panadeine or Naprogesic). Severe pain is unusual and should be reported to your doctor.

Wound care and dressings

Leave dressings intact for 24hrs unless they are soiled or wet. After that you may remove them, and either leave the wounds open, or (preferably) cover with a Band-Aid (it has been shown that keeping wounds slightly moist and warm enhances healing). Do NOT apply antiseptic creams, Dettol, Betadine, methylated spirit etc to the wounds. These are unnecessary and in most cases harmful to healing tissue. The best way to achieve a good scar is to leave the wounds alone until healed. Sutures will need to be removed around five days from the date of operation. After that you may massage the wounds with a moisturizer containing Vitamin E.

Some redness or 'flare' is usual, especially around the site of the wounds. If the redness is spreading or the wound is discharging, or you feel unwell or feverish, seek advice.

Showering

You can get the wounds wet the day after the operation, but avoid spas/baths/swimming pools until the sutures are out. Pat dry afterwards.

Sore throat and nausea

It is quite normal to have a sore throat and some nausea after the operation. The sore throat is due to the endotracheal (breathing) tube used whilst you are anaesthetised. Analgesics (pain killers) and small quantities of fluids will help. Nausea and drowsiness is due to the anaesthetic itself.

Vaginal bleeding

This is usually due to the curette which was done during the procedure, and may last about five days. Avoid sex, tampons and strenuous exercise whilst you are still bleeding. Some women notice that the stitch material that is used to close the top of the vagina inside the abdomen may fall out after a couple of weeks. It may look like a black piece of thread or fishing line. Do not be alarmed if this happens. Do not pull on any thread that seems attached inside the vagina.

Dizziness/loss of concentration

This may be due to the anaesthetic or analgesics (especially ones such as Panadeine or morphine). Avoid operating machinery, making important decisions or driving a car for at least 48hrs. You should take at least two weeks off work, or longer if your work involves strenuous activity or using machinery. Avoid strenuous exercise for about five days.

Post-operative review

You will need to see your GP in five to seven days to have the stitches removed. You will be offered an appointment at the hospital in around six weeks.

If you feel that you may have a significant problem that may require the advice of the hospital doctors after the operation you should not hesitate to contact the Emergency Department on (03) 8345 3636 or the unit registrar responsible for your surgery.